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SAN JOAQUIN Environmental Health Department -- COUNTY----. -- ,�,r,�„��;` Greatness grows her,:, SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 125 N Stockton St City/State/Zip Lodi, CA 95240 Phone Cross Street Locust St APN 043-084-130 Property Owner* City of Lodi Phone Address 221 W Pine Street City/State/Zip Lodi, CA 95240 c-57 contractor Cascade Environmental License# 1058336 Phone 916 638 1169 Address 3000 Duluth Street City/State/Zip West Sacramento CA 95605 Consultant/Sub- License# Phone Contractor Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15'bgs ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 20 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [21 PVC ❑ OTHER ® SOIL BORING 11 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes VNo Boring Dia: 2.25" Casing Dia: 1/4"TeflonCasing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND Al GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS HOSE [PIPE , OTHER q OTHER: U GROUT SEAL PUMPED? El Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) C `�❑ �I WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE i ❑ MUSHROOM CAP ❑ 3 feet below surface or feet bel w surface if>3 feet COMMENTS: SV f� S I�1 k VL out UV, ext'( La t.14. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with // San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. MAW W c"ClIM61A Title/Company Cascade Drilling Print NameRick Alcartado Date6/13/25 / DEPARTMENT USE ONLY r Application Accepted By: J Date Issued: �, ( ( 1"'` Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name i i,. � FA Address ( Z (,ti' �' FA# fJ l ( P R# FA PE WP Reviewed By Work Plan Date I]-C-57 ❑C-57 Authorization for Other to Sign Permit .Worker's Comp ❑Worker's Co p Waiver ❑Encroachment Permit (Access Agreement ❑ Lead Agency Approval MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $172 x 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 Site Mitigation Well Permit Application